DYSBIOSIS

QUESTIONNAIRE
AND SCORE SHEET
This questionnaire is designed for adults
and the scoring system is not as
appropriate for children. It lists factors in
your medical history which are known to
contribute to the disruption of normal
healthy gastrointestinal bacteria, directly or
indirectly promoting the overgrowth of
yeast, fungi and other pathogens, (Section
A), and symptoms commonly found in
individuals with dysbiosis related illness
(Section B and C).
Filling out and scoring this questionnaire
should help you and your physician
evaluate the possible role of dysbiosis in
contributing to your health problems. Yet
will not provide and automatic Yes or
No answer.
Note: Dysbiosis refers to the condition where

the normal healthy population of beneficial

bacteria in the intestines had been disrupted,
leaving it open to the overgrowth of yeast,
fungi, parasites and potentially harmful strains
of bacteria. This intestinal imbalance in turn
adversely effects other important systems via
toxic stress and interfering with nutrient
absorption and utilization.

SECTION A: HISTORY
For each yes answer in Section A, circle the
point score for that question. Total your
score and record it in the box at the end of
the section. Then move to sections B and C
and score them as directed.
1. Have you taken tetracyclines (Sumycin,
Panmycin, Vibramycin, etc.) or other antibiotics
for skin acne or anything else for one month (or
longer)?
25
2. Have you at any time in your life, taken
other antibiotics for respiratory, urinary or other
infections in shorter courses four or more times
in a one year period?
20
3. Have you taken an antibiotic drug even a
single course?
6
4.Have you, at any time in your life, been
bothered by recurrent or persistent prostatitis,
vaginitis or other problems affecting your
reproductive organs?
25
5. Have you taken birth control pills
for more than 5 years?
25
for more than 2 years?
15
for 6 months to 2 years?
8
6. Have you been pregnant..
two or more times?
5
one time?
3
7. Have you taken prednisone, Decadron or
other cortisone type drugs.
For more than 6 months?
For more than 2 weeks?
For 2 weeks or less?

25
15
6

8. Does exposure to perfumes, insecticides,

fabric shop odors and other chemicals provoke...
Moderate to severe symptoms?
20
Mild symptoms?
5
9. Are your symptoms worse on damp, muggy
days or in moldy places?
20
10. Have you had athletes foot, ring worm,
jock itch or other chronic fungous infections
of the skin or nails?
(Y/N)
Have such infections been
Severe or persistent?
20
Mild to moderate?
10
11. Do you crave sugar?

10

12. Do you crave breads?

10

13. Do you crave alcoholic beverages?

10

14. Does tobacco smoke really bother you?

10

15. Have you ever had a parasitic infection,

dysentery, or unexplained episode of prolonged
diarrhea and intestinal distress?
15
16. Have you ever consumed chlorinated (tap)
drinking water for more than 3 months?
15
17. Do you consume non-organic meat on a
regular basis?
15
18. Do you eat processed/packaged food
regularly?

20

19. Do you drink alcohol or coffee daily?

20

20. Do you have or have you ever had an ulcer,

colitis, crohns disease or diverticulitis?
35
Total Score, Section A:

______

SECTION B: MAJOR SYMPTOMS

SECTION C: OTHER SYMPTOMS

For each of your symptoms, enter the appropriate

figure on the line following the question:
If a symptom is occasional or mild = 3 points
If a symptom is frequent &/or moderate = 6 points
If a symptom is severe or disabling = 9 points
Add total score and record it in the box at the end
of the section.

For each of your symptoms, enter the

appropriate figure on the line following that
question.
If the symptom is occasional or mild = 1pt
If the symptom is frequent &/or moderately
severe = 2pt
If the symptom is sever &/or disabling = 3pt

30. Burning or tearing of eyes

______
31. Recurrent infection or fluid in ears ______
32. Ear pain or hearing loss
______
Total Score Section C:

______

Total Score Section A:

______

Total Score Section B:

______

Grand Total Score

1. Fatigue or lethargy
_____
2. Feeling of being drained
_____
3. Poor memory
_____
4. Feeling spacey or unreal
______
5. Depression
______
6. Numbness, burning or tingling
______
7. Muscle aches
______
8. Muscle weakness or paralysis
______
9. Pain &/or swelling in joints
______
10. Abdominal pain
______
11. Constipation
______
12. Diarrhea
______
13. Bloating
______
14. Troublesome vaginal discharge
______
15. Persistent vaginal burning or itching ______
16. Prostatitis
______
17. Impotence
______
18. Loss of sexual desire
______
19. Endometriosis
______
20. Cramps and /or other menstrual
irregularities
______
21. Premenstrual tension
______
22. Spots in front of eyes
______
23. Erratic vision
______
24. Eczema, dermatitis, psoriasis
______
Total Score, Section B

______

1. Drowsiness
______
2. Irritability
______
3. Poor coordination
______
4. Inability to concentrate
______
5. Frequent mood swings
______
6. Headache
______
7. Dizziness/loss of balance
______
8. Pressure above ears, feeling of head swelling and
tingling
______
9. Itching
______
10. Other rashes
______
11. Heartburn
______
12. Indigestion
______
13. Belching & intestinal gas
______
14. Mucus in stools
______
15. Hemorrhoids
______
16. Dry mouth
______
17. Rash or blisters in mouth
______
18. Bad Breath
______
19. Nasal congestion or discharge
______
20. Joint swelling or arthritis
______
21. Postnasal drip
______
22. Nasal itching
______
23. Sore or dry throat
______
24. Cough
______
25. Pain or tightness in chest
______
26. Wheezing or shortness of breath ______
27. Urgency or urinary frequency
______
28. Burning on urination
______
29. Failing vision
______

The grand total score will help you and

your physician decide if your health
problems are dysbiosis related. Scores in
women will run higher as 7 items in the
questionnaire apply exclusively to women,
while only 2 apply exclusively to men.
Dysbiosis related health problems are
almost certainly present in women with
scores over 180, and in men with scores
over 140.
Dysbiosis related health problems are
probably present in women with scores
over 120 and in men with scores over 80.
With scores of less than 60 in women and
40 in men, dysbiosis is unlikely to be
contributing to your health challenges.